BMS empowerment when to challenge - Transfusion Guidelines · :kdw pljkw d uhtxhvw eh iru" %orrg...
Transcript of BMS empowerment when to challenge - Transfusion Guidelines · :kdw pljkw d uhtxhvw eh iru" %orrg...
When to Challenge Requests!
Matt Hazell, (Consultant Clinical Scientist Red Cell Immunohaematology)
What might a request be for?
What might a request be for?
Blood productsRed cell units – normal, frozen, washed, irradiatedPlatelets – apheresis, in additive solution, washed, HLA or HPA selectedPlasma – FFP, Methylene Blue, Octaplas, CryoGranulocytes – apheresis, buffy coats, pooled buffy coatsPlasma derivatives – Human albumin solution, Clotting factor concentrates, Immunoglobulin solutions
What might a request be for?
Blood productsRed cell units – normal, frozen, washed, irradiatedPlatelets – apheresis, in additive solution, washed, HLA or HPA selectedPlasma – FFP, Methylene Blue, Octaplas, CryoGranulocytes – apheresis, buffy coats, pooled buffy coatsPlasma derivatives – Human albumin solution, Clotting factor concentrates, Immunoglobulin solutions
Laboratory investigations
Why Challenge requests?
Why Challenge requests?
Safety and Appropriate useThe safest transfusion is one the patient never receives; prevent mistakesprevent waste, deviation from guidance/license
Why Challenge requests?
Safety and Appropriate useThe safest transfusion is on the patient never receives; prevent mistakesprevent waste, deviation from guidance/license
Potential shortageCategory 1 Category 2 Category 3
Active majorbleeding
Cancer surgery(palliative)
Urgent but notemergency
surgery
Electivesurgery, likely to
require Tx
Emergencysurgery
Not lifethreatening
anaemia
Life threateninganaemia
Why Challenge requests?
Safety and Appropriate useThe safest transfusion is on the patient never receives; prevent mistakesprevent waste, deviation from guidance/license
Potential shortage
Cost
Why Challenge requests?
Safety and Appropriate useThe safest transfusion is on the patient never receives; prevent mistakesprevent waste, deviation from guidance/license
Potential shortage
Cost
REMEMBER!Provide the right blood component(s), to the right patient at the right time
Challenge may be unwelcome…
Challenge may be unwelcome…
Delay treatment – emergency, theatre
Challenge may be unwelcome…
Delay treatment – emergency, theatreInconsistent advice
Challenge may be unwelcome…
Delay treatment – emergency, theatreInconsistent advicePerception of different priorities
Patient care Vs Financial imperativesTreatement Vs adverse effects
Challenge may be unwelcome…
Delay treatment – emergency, theatreInconsistent advicePerception of different priorities
Patient care Vs Financial imperativesTreatement Vs adverse effects
RepetitionTask; clinical information
Challenge may be unwelcome…
Delay treatment – emergency, theatreInconsistent advicePerception of different priorities
Patient care Vs Financial imperativesTreatement Vs adverse effects
RepetitionTask; clinical information
Requester is not impowered
Challenge may be unwelcome…
Delay treatment – emergency, theatreInconsistent advicePerception of different priorities
Patient care Vs Financial imperativesTreatement Vs adverse effects
RepetitionTask; clinical information
Requester is not impoweredRequester isn’t used to being challenged
When to challenge requests?
When to challenge requests?
Consider challenging requests when for:• Elective or prophylactic use• High cost products• Off-license, or where specific guidance
contradicts
When to challenge requests?
Don’t challenge when there is:• Acute haemorrhage (for RBCs)
even if you haven’t had an up-to-date Hb etc.
• Requests for immediate O-(+)• When a delay in supply will further impact
(e.g. delaying critical procedures)
Consider challenging requests when for:• Elective or prophylactic use• High cost products• Off-license, or where specific guidance
contradicts
Example
Pre – operativePatients Hb is 90g/L3 units RBCs ordered
Example
Pre – operativePatients Hb is 90g/L3 units RBCs orderedBest managed with iron/EPO, is still low at surgery – TX acid (unless contraindicated)
Neutropenia• Patient is undergoing chemotherapy,
neutrophil count is 0.2x109/L, Patient has a bacterial infection
• Granulocyte order
Example
Neutropenia• Patient is undergoing chemotherapy,
neutrophil count is 0.2x109/L, Patient has a bacterial infection
• Granulocyte order• Best managed first with antibiotics
Example
Low platelet count• Patient has recoverable bone marrow
failure, neutropenic sepsis, antibiotics not been effective, granulocytes have been administered, platelet count before granulocyte transfusion was 10x109/L
• Platelets ordered
Example
Low platelet count• Patient has recoverable bone marrow
failure, neutropenic sepsis, antibiotics not been effective, granulocytes have been administered, platelet count before granulocyte transfusion was 10x109/L
• Platelets ordered• Granulocyte transfusions contain ~2 units
platelets
Example
Low platelet count• Patient is due to undergo lumbar puncture• Platelet count is 50x109/L• 1 unit platelet ordered
Example
Low platelet count• Patient is due to undergo lumbar puncture• Platelet count is 50x109/L• 1 unit platelet ordered• Procedure can be undertaken ≥40x109/L
Example
Anti-D Flow Cytometry• Long term inpatient - AML• Historic group O pos• On grouping, ?? D group• Patient is male• Investigation by flow cytometry ordered
Example
Anti-D Flow Cytometry• Long term inpatient - AML• Historic group O pos• On grouping, ?? D group• Patient is male• Investigation by flow cytometry ordered• Wouldn’t investigate by flow cytometry, patient
is historic D pos – would not be sensitised, patient is male and would not receive anti-D prophylaxis
Example
Summary
Discuss unclear requests
Avoid issuing inappropriate products to prevent harm
Identify patterns of requesting that fall outside guidelines to improve future requesting and supply
Longer-term feeding back to requesters
via the online requesting system (if applicable) - automatic
hospital transfusion committee
summoning clinicians to account for their practice